NEW YORK POLICE COMBAT ASSOCIATION

2012 Membership Application

NAME: ___________________________________________________ DOB: ____________________ ADDRESS: __________________________________________ CITY: __________________________ STATE: ____-- ZIP: _______ HOME PHONE: ________________CELL #__________________ E-MAIL: _____________________________________ DATE FIRST JOINED NYPCA_____________ DEPARTMENT: _________________________WORK PHONE: ( ) _______________________ NRA CLASSIFICATION REVOLVER: HM – MA – EX – SS – MRK – CLASS – UNC SEMI-AUTO: HM – MA – EX – SS – MRK – CLASS – UNC NRA NUMBER: _________________________ PISTOL PERMIT NUMBER: ____________________

RENEWAL FEES ___ RENEWAL $30.00, ___ NEW MEMBERS $40.00, ___ LIFE MEMBER ( 25 YEARS +) ____ TWO PERSON TEAM $5.00 EACH MEMBER TEAM NAME: _____________________________ TEAM CLASS: ______________ TEAM PARTNER: __________________________SHIRT SIZE:______________ Please make checks payable to NYPCA and mail to: Mark Dorfman 45 Treetop Circle Nanuet, New York 10954 845 352-7921

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